Insomnia: causes, CBT-I and when sleeping pills help
Insomnia disorder is trouble falling asleep, staying asleep or waking too early at least three nights a week for at least three months, despite having the chance to sleep, and affecting how you function during the day. Stress, worry, pain, heat, late meals and phones in bed commonly start or maintain it. Guidelines from the American College of Physicians, the American Academy of Sleep Medicine and NICE put cognitive behavioural therapy for insomnia (CBT-I) first. Sleeping pills are for short-term use only. Loud snoring with pauses in breathing needs checking for sleep apnoea.
Health writers · Aslam Clinic
means difficulty getting to sleep, staying asleep, or waking too early and not getting back to sleep, even though you have the time and a place to sleep, and it leaves you tired, irritable or struggling during the day. Almost everyone has bad nights. It becomes insomnia disorder when it happens at least three nights a week for at least three months. The first-line treatment is a structured talking and behaviour programme called (CBT-I), not sleeping pills.
Patients often describe it simply as neend na aana. It is common: in the United States, about 6–10% of adults meet the criteria for insomnia disorder, and it is more common in women and older adults.
Normal bad nights versus insomnia disorder
| Short-term sleep problems | Insomnia disorder | |
|---|---|---|
| How long | Days to a few weeks | At least 3 nights a week, for 3 months or more |
| Typical trigger | Exams, a wedding, a bereavement, illness, a heatwave, Ramadan | Often started by a trigger, then kept going by habits and worry about sleep |
| Daytime effect | Tired for a few days | Ongoing fatigue, poor concentration, low mood or irritability |
| What helps | Usually settles by itself once the trigger passes | CBT-I; sometimes short-term medicine alongside |
What causes it
Sleep researchers often think of insomnia in three layers: things that make a person prone to poor sleep (a naturally anxious temperament, older age), a trigger that starts it (stress, illness, grief, a new baby), and the habits and thoughts that keep it going long after the trigger has passed. The third layer is the one treatment targets. Lying in bed awake night after night teaches the brain that bed is a place for being awake and worrying.
- Mental health: , and — going over problems at night — are among the commonest causes. Insomnia also raises the risk of later depression.
- Physical health: pain, heartburn, passing urine at night (from high blood sugar, prostate problems or fluid tablets), breathlessness, an overactive thyroid, menopausal hot flushes, and restless legs.
- Substances: tea and coffee late in the day, cigarettes and naswar (nicotine is a stimulant), alcohol, and some medicines such as steroids.
- Local factors: summer heat, loadshedding that stops the fan at 2 am, mosquitoes, a shared room or a busy household, late heavy dinners, and scrolling on the phone in bed.
- Ramadan: waking for sehri and late taraweeh shorten and split sleep for a month. This is expected and usually resolves after Eid.
CBT-I: the first-line treatment
The American College of Physicians (2016) recommends CBT-I as the initial treatment for all adults with chronic insomnia. The American Academy of Sleep Medicine (2021) makes a strong recommendation for it, and NICE in the UK recommends newer sleep medicines only when CBT-I has been tried and not worked, or is not available or suitable. CBT-I usually runs over four to eight sessions and can be delivered face to face, in groups, by phone, or through structured online and app-based programmes. Its benefits last after treatment ends, which is not true of sleeping pills.
CBT-I combines several parts:
- Stimulus control — retraining the brain to link bed with sleep.
- Sleep restriction — temporarily limiting time in bed to build up sleep pressure.
- Cognitive therapy — tackling worries about sleep such as "If I don't get eight hours I'll be ill tomorrow".
- Relaxation techniques — slow breathing or muscle relaxation to reduce arousal at bedtime.
- Sleep education — including , but only as one part.
Stimulus control, explained
- Go to bed only when you are sleepy — not just tired, but eyes-closing sleepy.
- Use the bed only for sleep and intimacy: no phone, TV, eating or arguing in bed.
- If you have not fallen asleep after what feels like about 20 minutes, get up, go to another room or sit elsewhere in low light, and do something calm. Return only when sleepy. Repeat as often as needed. Do not watch the clock.
- Get up at the same time every morning, including weekends and after a bad night.
- Avoid daytime naps, or keep them short and before mid-afternoon.
Sleep restriction, explained
Sleep restriction sounds harsh, but it works. You keep a sleep diary for one to two weeks and work out how many hours you actually sleep. Time in bed is then limited to roughly that amount (usually not less than about five hours), with a fixed wake-up time. The mild sleep loss builds a strong drive to sleep, so sleep becomes deeper and less broken. As sleep improves, time in bed is extended in small steps, often 15 minutes a week. The first one to two weeks are hard, and daytime sleepiness gets worse before it gets better.
Why sleep hygiene alone is not enough
Sleep hygiene — a regular routine, a cool, dark, quiet room, no caffeine late in the day, no heavy meals before bed — is sensible and worth doing. But the American Academy of Sleep Medicine's 2021 guideline advises against using it as a stand-alone treatment for chronic insomnia, because on its own it does not work well enough. Most people with long-term insomnia have already tried the tips. They help most as part of CBT-I.
Sleeping pills: what they can and cannot do
Sleeping tablets can help for a short period, for example after a bereavement or during a crisis. They do not cure insomnia, and their effect wears off with regular use.
- such as alprazolam ("Xanax"), bromazepam ("Lexotanil"), lorazepam, clonazepam and diazepam, and the "Z-drugs" zolpidem and zopiclone, are for short-term use only — ideally no more than one to two weeks. They are habit-forming, cause next-day drowsiness, increase the risk of falls and hip fractures in older people, and are dangerous with alcohol or opioids. In Pakistan these tablets are often sold loosely without a prescription; that does not make them safe.
- Sedating antihistamines such as diphenhydramine and promethazine are sold as sleep aids and in cough syrups. The NHS notes they may help for only a week or two, and they can cause next-day grogginess, dry mouth and confusion in older people. The American Academy of Sleep Medicine suggests not using diphenhydramine for chronic insomnia.
- Melatonin has only modest effects for most adults with insomnia and is not recommended by the American Academy of Sleep Medicine for chronic insomnia; it is more useful for body-clock problems such as jet lag.
- Other medicines, including some sedating antidepressants and newer orexin-blocking drugs, may be used by a doctor in particular situations. Some are not widely available in Pakistan.
When to see a doctor
See a doctor if poor sleep has lasted more than a month or two despite sensible changes, if it is affecting your work, studies, driving or mood, or if you are relying on sleeping tablets. A doctor will look for medical causes, review your medicines, and screen for depression and anxiety.
What you can do tonight
- Fix a wake-up time and keep it every day for the next two weeks, however you slept.
- Put the phone on charge outside the bed, or at least across the room, from Isha onwards.
- Finish dinner two to three hours before bed, and switch to water or caffeine-free drinks after Asr.
- In summer, sleep in the coolest room, use cotton sheets, and plan for loadshedding with a charged fan or by wetting a cloth to cool the skin.
- Set aside ten minutes in the early evening to write down worries and a plan for each, so they are less likely to arrive at 2 am.
- If you are awake and frustrated in bed, get up and sit elsewhere until sleepy.
- Keep a simple sleep diary for two weeks — it is the first thing a clinician or CBT-I programme will ask for.
Common questions
Still not sure what to do?
Reading about a symptom only goes so far. A doctor who can ask you questions and examine you will get further in ten minutes than any article can.
